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Views from Across the Rubicon: The Rejected Physician Services Agreement

Posted on 28 September 2016 by Adam Kovacs-Litman

crossing-rubicon

August 14, 2016 marks a turning point for the history of health care in the province of Ontario. 63.1% of Ontario Medical Association (OMA) members rejected the Liberal government’s proposed Physician Services Agreement (PSA) and in so doing voiced their vehement disagreement with the trajectory of health care in Ontario.

This is not meant as a criticism of the PSA even though it is an agreement that is certainly worthy of our criticism. It is worth recognizing the many rational reasons physicians had for voting for the proposed agreement. The Liberal Government of Ontario’s rejected PSA was beyond disastrous. It was bad for the health care system and economically untenable. It intentionally underfunded health care at a rate lower than health care growth and would have necessitated longer wait lists, clinic closures, doctor relocations to other provinces and countries, and the delisting of medically necessary services. It also would have significantly cut individual physician salaries on a progressive basis over four years after accounting for inflation. With all that said, I’m still surprised that the PSA failed to pass. The agreement was despicable in objective terms, but still managed to provide stability and predictability in its sadism. Rejecting the agreement once again puts Ontario’s doctors at the mercy of the Liberal Government, a government that has shown its willingness to engage in unilateral action, even at the expense of Ontario’s doctors, tax payers and patients. The Liberal Government will likely impose an even harsher version of the rejected PSA and pass bill 210 (the ironically named “Patients First Act”) unamended. Bill 210 is punitive in nature and cripples the ability of health practitioners to manage their own practice while grossly expanding the scope of powers of the Minister of Health.

After comparing these two options, voting “for” this agreement seems maddeningly reasonable. The Ontario Government assumed that physicians would vote in alignment with their self interests and begrudgingly vote in favor of the devil they knew. What Ontario’s doctors gained by voting against the PSA is not something that is tangible. Rejecting the PSA was our profession’s confessional – it was our moral absolution. We will not be complicit in the erosion of our health care system. We are its champions and we will stand and defend it.

The word “advocacy” gets thrown around a lot in medicine and is a concept that those within the profession are perhaps overly familiar with. “Advocate” is one of the six cardinal roles that the Canadian Medical Association (CMA) identifies for physicians and “advocacy” is a deeply ingrained tradition of medicine. Physicians strive to advocate for their patients whether it’s by raising awareness for mental health, providing refugees with medical care, helping patients get access to the medications they need or just providing Ontarians with humanity and excellence in medical care. Rejecting the PSA is advocacy on a system level.

The rejection of the PSA marks a philosophical stand against the dismantling of health care that comes at great personal and professional cost. The Ontario Government likely crafted this agreement so that they could obtain the coerced consent of the medical profession and use it to legitimize further and continued cuts to health care. The language of the agreement would have made physicians responsible for increases in health care utilization, which some have compared to making firefighters financially liable for the number of fires they have to put out. This would have given the government political ammunition to blame inevitable future increases in health care expenditure on physicians. Signing the PSA would have made further advocacy considerably more difficult. It would have transformed would be advocates into hypocrites. This was an agreement that in its essence demanded silence in exchange for a slight reduction in the immediate rate of health care cuts. The Liberal Government tried to manufacture consent and it failed.

I hope that the freedom to continue to meaningfully advocate against harmful pieces of legislation is worth the heavy price that was paid. The medical profession is in an extremely precarious position and will no doubt face some trying times ahead. I hope that our rejection of the PSA is proof that we cannot be broken and that we will continue to advocate even in the face of continued propaganda and retaliatory measures.  Ontario’s doctors must serve as a check against the Ontario Liberal Government and their apparently willful destruction of our health care system.

There will come a time when we look back and reflect on the events that led to the creation of our modern health care system. In 1946, Tommy Douglas introduced the Saskatchewan Hospitalization Act, which became the model for health care across Canada. In 1984, the Canada Health Act introduced universal health care across the nation. In 1991, the OMA agreed to become a closed shop organization with mandatory membership. In 2016, the OMA rejected the Province’s Physician Services Agreement. August 14, 2016 was a day of significance.

Ontario’s doctors have crossed the Rubicon.

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Physician Burnout and the Cult of Medicine

Posted on 16 March 2016 by Adam Kovacs-Litman

I want there to be no mistake. Medicine is the most incredible profession. It intertwines a divine understanding of scientific principles with their very human application. It is one of the few professions that starts with atoms or cells and ends with people and emotions. It begins with universal laws and ends with subjective truths. Medicine is science, but it’s also poetry. Medicine exists in cosmic balance, but that balance is temperamental.

Those working within the health care profession are well aware of a phenomenon known as “physician burnout”. It is characterized by emotional exhaustion, depersonalization, cynicism and a lack of fulfillment. Studies estimate that physician burnout can affect as many as 65% of physicians. Many are surprised that such an intellectually and emotionally rich vocation can leave one drained and unfulfilled. Dr. Christina Maslach, an American psychologist and creator of the Maslach Burnout Inventory (MBI) perfectly described burnout as “an erosion of the soul”.

Maslach’s description makes a lot of sense to me because medicine is not a profession in the traditional sense. Medicine is a religion. It demands long hours and years of study – it demands sleepless nights and tireless days – in some aspects, it demands indoctrination.

We do not wear religious shawls, but we do wear white coats. We do not worship stars, crosses or crescent moons, but openly revere snakes coiled around a winged staff. Our holy text is the Hippocratic Oath and our prophets are many: Hippocrates of Kos, Galen of Pergamon, Lister of West Ham, and Koch of Clausthal are but a few. We even have modern day prophets like William Osler and Atul Gawande and false prophets like Ben Carson or Eric Hoskins.

Viewing medicine as a religion makes physician burnout easier to understand because a religion demands that life be made secondary to the divine. Medicine demands that patients always be put first and it demands that you live your life in the shadow you cast. Some have called medicine a Black Art and in some ways it is. It is perhaps the only profession that consumes the soul of the practitioner. The quest of medicine is Faustian. Many medical practitioners will pay a heavy price for the miracles they work.

I’ve read much of the literature on physician burnout and while the conclusions are accurate, they are often uninsightful. Deckard et al. (1994) correctly identify emotional exhaustion as the leading cause of burnout. Gundersen (2001) correctly concludes that certain personality profiles are more at risk of burnout. Shanafelt (2009) even claims that we can combat burnout by realigning organizational values such that patient care be given equal importance to physician well-being.

Shanafelt’s study best addresses the crux of the issue. Nothing will change unless we reorganize the value structure of medicine. Doctors burn out because they practice a toxic ideology. A man may subsist, but they cannot survive without a soul.

I believe that people really do go into medicine for noble reasons. They want to make a difference, help people… change the world, and are often willing to sacrifice themselves in the process. Unfortunately sacrificial offerings will not make the elusive “work-life balance” any easier to attain.

This is not a critique of medicine. I repeat that medicine is an incredible profession and one that I am grateful to be a part of. This is instead an invitation to examine one’s values and the values that are thrust upon us.

A man cannot sustain himself on ideology. Anyone who eats the body of Christ and nothing else will receive poor nutritional value. Surprisingly, the blood of the Lord is not rich in iron.

References

Deckard, G., Meterko, M., & Field, D. (1994). Physician burnout: an examination of personal, professional, and organizational relationships.Medical care, 745-754.

Gundersen, L. (2001). Physician burnout. Annals of Internal Medicine,135(2), 145-148.

Maslach, C., Jackson, S. E., & Leiter, M. P. (1996). Maslach burnout inventory manual. Consulting Psychologists Press.

Shanafelt, T. D. (2009). Enhancing meaning in work: a prescription for preventing physician burnout and promoting patient-centered care. JAMA,302(12), 1338-1340.

Shanafelt, T. D., Boone, S., Tan, L., Dyrbye, L. N., Sotile, W., Satele, D., … & Oreskovich, M. R. (2012). Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Archives of internal medicine, 172(18), 1377-1385.

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The Fiddler and the Fire: The Decline and Fall of The Health Care System

Posted on 15 October 2015 by Adam Kovacs-Litman

The Ancient Roman Empire did not fall in a day. And it certainly didn’t fall because barbarians were knocking at the gate. The decline and fall took hundreds of years while ignorance, apathy and conceit ate away at the soul of empire. Rome rotted from within.

The Canadian health care system is critically ill. We are faced with a rapidly aging population and health care expenditures that consistently rise faster than both the rate of inflation adjusted for population and provincial government revenues. The writing is on our crumbling walls. The signs are all around us. The Canadian health care system is fundamentally unsustainable, yet we shrug our shoulders and trudge on with the confident irreverence of Ancient Rome.

The Liberal Government of Ontario addressed this problem of unsustainability by conjuring the wisdom of charlatan economists. As health care expenditures continue to grow, the government will cut $580 million over two years while demanding that physicians shoulder the burden of increased health care costs through claw backs and reconciliation. An additional 1.3% cut was just announced September 2015, raising total cuts to 6.9% plus reconciliation and inflation. The situation is even worse for family practitioners, particularly new graduates who will be barred from joining Family Health Organizations. Year after year, health care costs will continue to rise. A policy of reconciliation cannot by definition provide a meaningful long-term solution. The government’s unilateral action demonstrates an unwillingness to engage with the Ontario Medical Association (OMA). The Emperor refuses to heed the advice of the Senate.

The OMA has responded with an official policy of public advocacy and awareness. It is well intentioned, but perfectly obvious to all involved that this tact will fail to produce political dividends. Despite its low likelihood of leading to policy changes, some physicians may be appeased by the OMA’s actions. Unfortunately, one can hardly blame the OMA. What else is there for an organization lacking the means to exert any form of meaningful recourse? What else is there but bread and circuses?

This is not a policy brief advocating for any particular kind of action. This is instead a prophecy for Canadian health care. Rome will fall. This article is interested in how it will fall and what will rise from the ashes.

Our public access health care system is one of the biggest misconceptions surrounding the Canadian identity. Canadians pride themselves on the grandeur of our system and mock the Americans for the inefficiencies in theirs. We support the idea of our health care system with a religious devotion, making it immune to critique and impervious to logic. It is almost humorous, that for all our zealotry, the Canadian health care system is one of the worst of any developed nation. Many other countries have much more extensive public systems, offering coverage for optometry, dentistry, home care and pharmaceuticals while costing much less. Dramatic structural changes to the Canadian health care system are not only inevitable, but will likely prove advantageous in the long run.

As doctors gain more public support and the economic benefits of further pay cuts become marginal and untenable, the government will abandon this plan of attack. Instead, the government will scour for cost savings within the health care system. It will find some, particularly within hospitals stifled by expensive bureaucracy, but not enough to offset ever growing health care costs. Next, we will see funded services be cut with increasing frequency in a fruitless effort to stave off costs. It will begin with simple blood tests that few notice missing before progressing to increasingly important treatment options. This is already happening in the United Kingdom, whose health care system shares a similar plight (though perhaps for different reasons). In January 2015, the NHS defunded 25 cancer treatments, cutting short the lives of approximately eight thousand patients. When philosophical grumblings about health care became hard realities faced by baby boomers entering the latter part of their life, health care will become a national issue. The defunding of important services, a decline in the quality of care and even longer wait times are not acceptable when you are in your 70s, 80s, 90s or beyond.

When health care becomes the election issue, each party will present their own vision for what health care ought to be and none will resemble our current system. Variations on similar ideas will emerge throughout the provinces. Hospitals will receive considerable pay cuts as non-hospital medical centers like long-term care facilities receive increased funding. Health care will finally become more distributed with hospitals losing their stranglehold over the heart of medicine. Regulations surrounding billing will gradually loosen as the government embraces elements of the free market. Physicians will begin to splinter off from the public system, resulting in more private practices and clinics. Health care will continue to grow at a rate that exceeds inflation, but this growth will be largely financed by entrepreneurs and willing members of the public without depleting government coffers.

Health care will slowly become sustainable, unfortunately first it will burn.

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